Last week, at the RCEM Annual Scientific Conference, a document endorsed by all the big players in healthcare (in England at any rate) was released with a degree of fanfare. Those of us who work in Emergency Departments are only too aware of the challenges that are facing us and this report aimed to address some of these, with specific reference to the medical workforce.
The press release that accompanied its release included Jim Mackey, currently the Chief Executive at NHS Improvement saying: “The workforce of our emergency departments have been working incredibly hard to ensure that they continue to provide safe, high quality care to patients despite continued staffing pressures.
“The commitment to train more emergency medics year on year and to develop the roles of advanced nurse practitioners and associate physicians further, while working to reduce the attrition rates of our current staff, provide a clear plan on how we and our partners will work together to tackle some of the staffing pressures facing emergency departments.
“These commitments will ensure that our A&Es are appropriately and sustainably staffed, with skill mixes that match the changing needs of our society, that provide a supportive environment in which to train emergency medicine trainees and establish these departments as attractive places to build a long and fulfilling career.”
If you want to read the whole thing (and I would recommend you do – it’s not that long and has rather a lot of repetition) you can find it here
The first section discusses how we can expand the workforce and includes several different types of clinician. 
Expansion in training posts in undoubtedly welcome, but this is clearly dependent on being able to recruit to these posts. Many areas currently have gaps on their training rotations and increasing available places will make no difference here.
The expansion in training posts will, of course, also bring further challenges in a few years when these doctors are looking for consultant posts. A new consultant post costs a hospital about £100,000 per year (when you factor in other costs, such as pension contributions, on top of salary). These extra training posts will therefore need an additonal ongoing investment of £10 million per year (so £40 million extra per year by the end of the four years). This cost will have to be borne by already cash strapped hospitals and I fear there may simply not be enough consultant posts available.
Later in the document it also describes the move that all trainees in higher specialist training can work less than full time, which I am sure some will choose. This may actually that mean we do not see any increase in “whole time equivalents” in the numbers of doctors in emergency medicine training at all (in fact we may even have fewer).
The use of Advanced Care Practitioners (ACPs) is now becoming well established and I am delighted that my Trust has embraced this. There is still some uncertainty about where these clinicians can contribute to a rota (at CT3 level seems most likely), but I have had nothing but a positive experience working with them. The key here is that they are trained to a level to function as decision makers across the whole ED and that their referral decisions are respected by in patient teams.
Physician Associatess (PAs) are not something I am familiar with personally. They are an initiative imported from the US, where they have been very helpful particularly in the management of minor illness and injury. In the UK we already have a very well established group of Emergency Practitioners (also known as Emergency Nurse Practitioners) who have been managing minor injury for years and the recent investment by the Department of Health of £100 million, means many EDs will now have co located general practice managing minor illness, so it is difficult to see where PAs will fit in.
I remain skeptical about how they will impact on the workload of the ED, and the consultants in particular, especially with the care of patients in “Majors” The hardest part of my job is having to review multiple patients in the department, making quick decisions often based on the findings of others. How often have you thought “it would have just been quicker if I had seen the patient myself” and I worry this may occur with PAs, especially in the first few years. And as we know, Emergency Physicians have a very short attention span and are likely to lose interest in this quickly if it is not working.
The role of “Clinical Educators” is promoted and, at first glance, this seems like a good idea. Dedicated time on the shopfloor for consultants to spend with trainees “improving the training environment”. The trusts with the worst scores in the GMC survey will get extra funding to support this, whilst others will just be expected to do it. There is more about the Physicain Associate career path here.
So how will this work in reality? Consultants will have these sessions job planned from their “SPA” (Supporting Professional Activities) non clinical sessions and will be rostered for sessions as a “clinical Educator”. This all sounds great, until it gets busy….
Then these experienced doctors will be on the shopfloor, but not actually seeing patients themselves, while their colleagues struggle on. Similar to sitting in a life raft, sipping G&Ts, while you watch your friends drown. And even if you don’t decide to help yourself I am sure managers will urge you to “just see a couple of patients would you?”. The dedicated training time is lost (as is the precious non clinical time). To make this work will require strong leadership and some rule setting from the off, in order to ensure this isn’t just a way of SPA becoming DCC (direct clinical care) by the back door.
As with many of these initiatives, they will not be available (and funded) for everybody.
Perhaps rightly, the funding will focus on those who are perceived to need it most, which may leave those in the “middle of the table” continuing to find life very hard, whilst those “succeeding” cruise on and those in the “relegation zone” are supported.
The report also urges us to “enagage other specialties” 
and how you read this section very much depends on whether you are a “cup half empty” or “cup half full” type of person. The more positive amongst us will applaud this – won’t it be great to have the medical and surgical teams alongside us, working hand in hand? Others may think that this will force Emergency Medicine more and more towards a “triage” role and leave us managing the conditions that don’t interest those clever inpatient doctors. The truth is, as usual, problem somewhere between the two and will depend on strong clinical leadership to ensure that all the clinicians working in and with the Emergency Department feel valued.
The report concentrates on the trainee workforce, but says relatively little about consultants and their wellbeing, except for this….
I’m afraid I think this is where I believe this document has completely missed the mark and left a tribe of consultants who are neither newly appointed or approaching retirement floundering. I freely admit, that I am one of this group: who has been a consultant for about a decade and needs both new challenges and a break from the daily grind of the shopfloor. For many this is done via taking on other roles, such as in management or education, but this isn’t possible for all.
And this is where we need urgent action – our emergency physicians of the future, who are in training (or considering entering one of the newly available spots on the programme) need to have role models to whom they can look up and aspire to be like. To be able to say “wow, the life as a consultant is really amazing, fulfilling and I want to be just like that” (without a hint of irony). They see colleagues in different specialties and perceive their lives to be very different – most are most certainly not working night shifts and seeing drunk people with sprained ankles at 4am. Which life would you choose for your 40s and beyond?
If we don’t have urgent action to ensure Emergency Medicine is a fulfilling career for the whole of your working life, then I fear that no matter what we do now to increase those coming into the specialty we will lose a tribe of highly experienced doctors who appear to have been forgotten.
It is, without a doubt, great to see that the major organisations involved in Emergency Care are working together to form a coherent vision for how the workforce will look in future. In a resource limited health service, how funding is allocated will always be a challenge. This document goes some of the way towards addressing this, but there is still work to be done. We will need innovative solutions and some of these may be confronting to the current ways we work. Not everything we try will suceed, but we must keep trying. We need to continue to work together to ensure our beloved specialty continues to flourish and the patients who need us are getting the highest standard of care possible, from motivated and valued staff,
BW,
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Thanks Iain for that timely review.as a consultant in my 50’s still doing night shifts & seeing intoxicated people with sprained ankles-we do need to be there when the patients are if we are going to support our teams.. WE also need to get better at letting our juniors know that EM is the ‘go to place for flexible working’.If I do 2 night shifts -with the proper remuneration-that’s a weeks work -when we are present -it’s intense but with the right rota organisation -we get a lot of down time .There is a down side to working office hours that no one seems to mention…
Thanks Ian – very wise analysis of the document. I was particularly struck by the lack of concrete improvements for the trainees – apart from the clinical educator role (I share your concerns) there appears to only be a promise of a few days leadership training per year, and nothing much else.
In terms of Physician Associates, I feel much more positive – the students we have had through our department are excellent and I am looking forward to working with them. Our model would be to have them working primarily in majors and operating a broadly similar model to acute medicine: they see and assess the patient, write the notes, and we do a brief face-to-face consultant review with the patient to confirm the facts and fine-tune the plan. Certainly in departments with relatively few junior doctors, where seniors do a lot of “seeing patients themselves” rather than “reviewing juniors’ patients”, PAs will I think have a lot to add.
As a trainee Physician Associate with a job lined up in a Busy City A&E I can accept the points you put forward about our limited experience in the first few years of training. However during my placements in the ED I have clerked patients, come up with management plans and initiated treatment in the same way any of your junior medics might.
Our strength comes from the fact that we do not rotate out of post in the same way junior medics do so we are able to offer the department (and you the consultant) a junior role that has continuity with our skills and knowledge growing the longer we are in post.
I hope that once you have worked with a PA we can turn your scepticism around. I for one am excited about the challenge of working in a busy ED.